Therapy Waitlist Registration Form
Client Full Name
*
First Name
Last Name
Contact Full Name (e.g., parent)
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
How did you hear about us?
Please Select
Word of Mouth
Internet
Previous client
Perth Kids Hub
Other
Please Specify
Reason/s for therapy:
What is your preferred location for services (tick all that apply):
*
In the office
Mobile - school visit
Mobile - home visit
Telehealth
If you prefer mobile services, please advise the suburb of the preferred location:
Please advise how you will pay for services:
*
NDIS
Medicare/Mental Health Care Plan - rebate plus gap payment
Private fee paying
Submit
Should be Empty: